Failure to Prevent Elopement and Injury Due to Inadequate Supervision and Malfunctioning Door Alarm
Penalty
Summary
A deficiency occurred when a cognitively impaired resident with a diagnosis of vascular dementia, atrial fibrillation, and heart failure, who was assessed as being at high risk for elopement, was admitted for a seven-day hospice respite. The resident began exhibiting wandering and exit-seeking behaviors shortly after admission. Despite these behaviors and the resident's high risk for elopement, there was no care plan implemented to address the resident's cognitive impairment or elopement risk. The resident was initially placed on an unsecured floor and later moved to a secured memory care unit (MCU) with a Wanderguard device applied. On the day of the incident, the resident was last seen in the common area near the nurse's station, eating a snack. Staff, including the DON and a CNA, left the area to provide care to another resident, leaving the resident unsupervised. Approximately 40 minutes later, staff realized the resident was missing. A search was conducted, and the resident was found at the bottom of a stairwell between the second and third floors, having fallen down 11 cement stairs. The resident suffered multiple injuries, including fractures to the left scapula, several ribs, abrasions, lacerations, and contusions. The resident did not recall the fall and was transported to the hospital for evaluation and treatment. Investigation revealed that the stairwell door alarm was not functioning due to wires that had been chewed through by rodents, resulting in the alarm not sounding when the door was opened. Maintenance records showed no documentation of prior issues with the door alarms, and the last documented check of the alarm system was several weeks before the incident. The secondary alarm at the nurse's station was faint and likely went unnoticed. The lack of a completed elopement risk assessment upon admission, absence of a care plan for elopement risk, and failure to ensure the functionality of the door alarm system contributed to the resident's unsupervised exit and subsequent fall.